- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,181.14 / $1,181.14 / $1,181.14
| Facility | | $1,181.14 | $1,181.14 | $1,181.14 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,165.88 / $1,288.13 / $2,144.41
| Professional | | $1,165.88 | $1,288.13 | $2,144.41 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $5,670.01 / $10,935.61 / $21,331.89
| Facility | | $5,670.01 | $10,935.61 | $21,331.89 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,247.94 / $3,814.72 / $4,626.71
| Professional | | $2,247.94 | $3,814.72 | $4,626.71 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,749.72 / $4,291.60 / $10,324.04
| Facility | | $2,749.72 | $4,291.60 | $10,324.04 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,178.34 / $3,903.31 / $5,366.58
| Professional | | $2,178.34 | $3,903.31 | $5,366.58 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,382.88 / $3,916.37 / $8,129.16
| Facility | | $2,382.88 | $3,916.37 | $8,129.16 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,163.58 / $3,561.14 / $4,906.64
| Professional | | $2,163.58 | $3,561.14 | $4,906.64 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $1,249.64 / $2,097.00 / $3,680.29
| Facility | | $1,249.64 | $2,097.00 | $3,680.29 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,480.92 / $2,988.97 / $9,488.08
| Professional | | $1,480.92 | $2,988.97 | $9,488.08 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $796.00 / $3,500.00 / $8,152.00
| Facility | | $796.00 | $3,500.00 | $8,152.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,390.30 / $2,709.63 / $5,187.87
| Professional | | $1,390.30 | $2,709.63 | $5,187.87 |